Health and Life Benefits Summary Plan Description First Data Corporation January 2016
First Data Corporation (the Company or First Data ) is the plan sponsor of the plans described in this summary plan description (SPD). The SPD is being provided to you and it describes benefits provided to you by your plan sponsor and your rights under the plan. The SPD is based on official plan documents. It is not, nor is it intended to be, the official plan document, or a contract between First Data and any employee or contractor, or a guarantee of employment. Every effort has been made to ensure the accuracy of this information. In the unlikely event that there is a discrepancy between the SPD and the official plan documents, the official plan documents will control. First Data reserves the right to amend, suspend, or terminate the plan(s) or program(s) at any time. First Data has the discretionary authority to interpret the terms of the plan(s) summarized in this document and determine your eligibility for benefits under its terms. In some cases as indicated, that discretionary authority has been delegated to a third party. In addition, there may be situations where the plan(s) provides different benefits to different employee groups. This SPD provides only those benefits that are applicable to you based on your employee group. This SPD is available to you online through the benefits website at www.firstdatabenefits.us, or through Your Benefits Resources at http://resources.hewitt.com/firstdata. You have access and the ability to view the SPD on the websites, and print pages of this SPD from the website. You also have the right to receive a paper copy of the SPD, free of charge, by going to the Health and Life page on Your Benefits Resources, (click on Forms and Materials, then selecting the H&L espd, and Request Materials) or by calling the First Data Health and Life Help Desk. If there are any discrepancies between the information on the website and your printed copy, the website version will control. While this SPD can be a useful tool, it is not your only information resource: Call Health Advocate at 1.866.799.2728 with questions related to general benefits education, how the health plans work, locating providers, and access to the Employee Assistance Program. Call First Data Health and Life Help Desk at 800.965.2238 with questions about eligibility and enrollment, or for assistance with inquiries related to the non-health plans (vision, legal assistance, life, disability, business travel accident, health savings account, flexible savings account). At Your Benefits Resources website, you can enroll into First Data s Health and Life Benefit Plans, and review your benefit coverage and dependent information. You can access the Your Benefits Resources website by o Going to http://resources.hewitt.com/firstdata o Going to www.firstdatabenefits.us, and clicking the Enroll in Health and Life Benefits link. The claims administrators and insurance carrier sites are also important resources for information. 1
Table of Contents Benefits Overview... 7 Annual Benefits Salary... 9 Employee Eligibility for Coverage... 9 Coverage You Receive Automatically... 11 Coverage You Need to Elect Optional Coverage... 11 When Coverage Begins... 12 Dependents You Can Cover... 13 Dependent Verification Requirements... 14 Spouse/Domestic Partner Coverage (Dual Coverage Exclusion)... 15 Domestic Partner Eligibility Rules... 15 Dependent Eligibility Rules... 16 Rules for Full-Time Students (Applies to Child Life and Voluntary AD&D Coverage)... 16 Rules for Disabled Children... 17 Qualified Medical Child Support Order... 17 Employees in the Same Family... 18 Enrollment... 20 Initial Enrollment... 20 Annual Enrollment... 20 Coverage Categories... 21 Changing Your Coverage... 22 When Eligibility Ends... 31 When Coverage Ends... 32 Coverage You Can Continue... 33 COBRA and Conversion Rules... 34 Continuing Coverage under COBRA... 34 COBRA Qualifying Events... 36 Qualified COBRA Beneficiaries... 37 Conversion Rules... 38 Certificate of Group Health Coverage... 40 Medical Plan Overview... 41 2
Medical Plan Options... 41 Medical Terms You Should Know... 41 Enhanced and Standard Medical Plans - Overview... 50 How the Prescription Drug Benefit Works... 52 How the Health Savings Account Works... 52 Limited-Purpose Health Care Flexible Spending Account... 56 Enhanced and Standard Medical Plans Summary of Benefits... 57 Enhanced Medical Plan Summary of Benefits:... 58 Standard Medical Plan Summary of Benefits... 64 Out of Area Medical Plan - Overview... 70 Out of Area Medical Plan Summary of Benefits:... 71 Medical Plans - Service Details... 75 What's Not Covered... 75 Medical Plans What s Covered... 81 Physician Services... 81 Preventive Care... 82 Out-Patient Diagnostic Services... 83 Surgery Services... 84 Hospital Services... 84 Family Planning... 85 Medical Therapy... 88 Covered Medical Supplies... 90 Other Medical Services Covered... 90 Care at Alternate Sites... 94 Organ and Tissue Transplants... 96 Condition Management Program... 97 In-Network Providers... 98 Primary Care Physicians (PCPs)... 99 Specialist Care Physicians (SCPs)... 99 Deductible... 100 Coinsurance... 100 Appealing the Claims Administrator's Decision... 102 Out-of-Pocket Maximum... 104 Reasonable and Customary (R&C) Limits... 104 3
Emergency Care... 105 Coordination of Benefits... 105 Prescription Drug Program... 108 Generic and Brand Name Drugs... 111 Mandatory Generic Program... 112 Mail Order Incentive Program... 112 Specialty Pharmacy Medications Program... 112 Pharmacy Management Programs... 113 Covered Drugs... 117 Drugs Not Covered... 118 Prescription Drugs and Changes to the Formulary... 119 How to Appeal Denied Claims... 121 Aetna Global Medical Plan - Overview... 121 Triple S Medical Plan Overview... 123 Hawaii PPO Medical Plan Overview... 123 HealthyFirst Wellness Incentive Program... 126 Tobacco Cessation Program... 127 Employee Assistance Program... 128 Dental Plan Overview... 131 Dental Plan Options... 131 Dental Terms You Should Know... 131 Preferred Dentist Provider (PDP) Plans... 133 MetLife Preferred Dentist Provider Plan A Summary of Benefits... 134 MetLife Preferred Dentist Provider Plan B Summary of Benefits... 135 What's Not Covered Metlife PDP Plan A and Plan B... 136 Preventive and Diagnostic Services... 137 Basic Restorative Services... 137 Major Restorative Services... 138 Orthodontia Services... 139 Dental Deductible... 139 Dental Coinsurance... 140 Filing Dental Plan Claims... 141 How to Appeal Denied Claims... 142 Dental Maintenance Organization (DMO) Dental Option... 142 4
Vision Plan Overview... 144 How the Plan Works... 144 Vision Plan Benefits... 145 What's Not Covered... 147 Filing Vision Plan Claims... 148 How to Appeal Denied Claims... 148 Flexible Spending Account Overview... 150 How Flexible Spending Accounts Work... 150 Health Care Flexible Spending Account... 152 Eligible Health Care Expenses... 152 Limited Purpose Health Care Flexible Spending Account... 154 Day Care Flexible Spending Account... 155 Care$ Benefit... 155 Eligible Day Care Expenses... 157 Filing Claims for Reimbursement... 158 Flexible Spending Account Debit Card (HealthHub)... 159 How to Appeal Denied Claims... 160 Life and AD&D Insurance Overview... 162 Insurance Plan Coverage... 162 When Life and AD&D Insurance Benefits End... 163 Basic Life Insurance... 163 Supplemental Employee Life Insurance... 166 Spouse/Domestic Partner Life Insurance... 168 Child Life Insurance... 169 Basic Accidental Death and Dismemberment (AD&D) Insurance... 170 Voluntary Accidental Death and Dismemberment (AD&D) Insurance... 172 Additional Benefits (AD&D)... 174 Life and AD&D Insurance Beneficiaries... 179 Imputed Income... 181 Evidence of Insurability... 182 Filing Life and AD&D Insurance Claims... 182 Exclusions... 183 Reductions in Coverage Amount... 184 Business Travel Accident Insurance... 186 5
Who Is Covered... 187 Covered Business Travel... 187 Business Travel Accident Insurance - Additional Plan Benefits... 188 How the Plan Pays Benefits... 194 Business Travel Accident Claims... 195 Exclusions... 195 Disability Plans Overview... 196 How Disability Benefits Work... 196 Short-Term Disability (STD) Plan... 196 Short-Term Disability (STD) - Additional Plan Rules... 197 When Benefits End... 200 Exclusions... 201 Long-Term Disability (LTD) Plan... 201 Long-Term Disability - Additional Plan Rules... 203 Two or More Disabilities... 204 Disabilities Due to Mental Disorder, Alcohol, Drug, and Substance Abuse, or Addiction... 204 Disabilities Due to Neuromuscular, Musculoskeletal or Soft Tissue Disorder and Chronic Fatigue Syndrome and related conditions... 205 Accidental Dismemberment and Loss of Sight... 206 Definition of Disability... 207 Vocational Rehabilitation... 208 Applying for Benefits... 210 Exclusions... 214 Recovery from a Disability... 214 Adoption Assistance... 216 How the Program Works... 216 Tuition Reimbursement Policy... 218 For More Information... 221 Legal Assistance Plan... 223 Important Plan Information... 229 Plan Identification... 229 Benefit Plans Sponsor and Administrator... 231 Benefit Review Process - Disability and Non-Group Health Plans... 251 6
Benefits Overview The Health and Life Benefits are designed to promote health and wellness and protect you financially in case of illness, accident, or death. First Data offers a variety of plan options and coverage levels so you can choose the coverage that's right for you. Enrolling for Coverage You receive some coverage automatically, while other coverage you will need to actively enroll. If you do not enroll, you are assigned coverage which may mean no coverage in certain benefits. As a new employee, you can enroll for benefits which remain in effect for the rest of the current plan year (January 1 to December 31). You can then make changes during any annual enrollment period for the upcoming plan year. As a current employee, you can change your coverage during any annual enrollment period for the upcoming plan year. If you have a qualified change in status, you can make mid-year changes to your benefit coverage that are consistent with your status change. If You Have Other Coverage Available You may be eligible for coverage under more than one medical or dental plan. For example, your spouse/partner may be able to cover you under his or her employer's plans. Having coverage under more than one medical or dental plan does not necessarily mean you get more benefits. Most plans coordinate benefits, which prevents duplication of coverage. Review information for other plans before making your benefit selections. Dual Coverage Exclusion - If your spouse or domestic partner is eligible for medical coverage from his/her employer regardless of whether he/she is enrolled in that coverage your spouse/domestic partner is not eligible to participate in First Data s medical plans. If no employer coverage is available for your spouse/partner, you must certify spouse/partner eligibility for First Data before enrolling him/her in your First Data medical plan. Paying for Coverage The company pays for certain benefits, while some plans require you to enroll and pay your share of the cost or all of the cost through payroll deductions. Your payroll deductions may be on a before-tax or after-tax basis, depending on the type of benefit. 7
Before-tax payroll deductions include: Medical (other than most domestic partner coverage) Dental (other than most domestic partner coverage) Vision (other than most domestic partner coverage) Health Savings Account Health Care Flexible Spending Account Day Care Flexible Spending Account Before-tax deductions are taken before income taxes are calculated, which means these "tax- free" dollars are not subject to federal, Social Security, and in most cases, state taxes. Since your income is lower, you pay less in income taxes. You can elect to pay for this coverage with after-tax dollars. If you wish to pay with after-tax dollars, contact the First Data Health and Life Help Desk at 800-965-2238 and follow the prompts for additional information. After-tax payroll deductions include: Voluntary Accidental Death and Dismemberment Insurance Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Voluntary Long Term Disability Legal Assistance Plan Voluntary Critical Illness and Accident Insurance Plans Most domestic partner coverage for Medical, Dental and Vision Insurance Payroll deductions begin or change as soon as administratively possible. Imputed Income Group Health Benefits Group health benefits are generally tax-free to employees, spouses, and dependents, but because domestic partners are not considered spouses under the Internal Revenue Code (IRC), they may not receive tax-free health care benefits from employer benefits plans. So, any benefits received by a domestic partner must be taxed. The imputed income is calculated on the entire full premium benefit amount. The domestic partner coverage is considered after-tax because the imputed income is applied to the full premium amount. This amount is added to your total annual compensation reported to the IRS. It appears on your W-2 statement and is taxable at your regular income tax rate. 8
Annual Benefits Salary Your annual benefits salary is used to calculate your coverage amount for these plans: Basic Life Insurance Basic Accidental Death and Dismemberment Insurance Business Travel Accident Insurance Short-Term Disability Basic Long-Term Disability Voluntary Long-Term Disability Your annual benefits salary is also used to determine medical plan contribution pricing, Health Savings Account funding by First Data, medical out-of-pocket maximums, your eligibility for the CARE$ benefit program, and life and disability pricing and coverage amounts. When you join First Data, your annual benefits salary for the plan year is calculated using your base salary, unless your pay is commission based, in which case your annual benefits salary is considered to be $30,001. If the base salary is greater than $30,001 and commission is part of the compensation, the base salary will be the annual benefits salary. After that, your annual benefits salary is determined as of the annual "salary freeze date" (usually in August of each year). If your salary increases or decreases during the year, your annual benefits salary and coverage amounts will be adjusted at the next salary freeze date, and will go into effect the following plan year Your annual benefits salary includes: Your base salary (including your base compensation for the year, before any salary reduction for before-tax contributions to the savings plan, Flexible Spending Accounts, and other health and insurance plans). Commissions earned from September August of the previous plan year. Annual benefits salary does not include: Overtime Bonuses Shift differential Any other form of compensation you might receive Employee Eligibility for Coverage Who Is Eligible 9
You are eligible for coverage under Health and Welfare Benefit Plans if you are on the U.S. dollar payroll as a regular full-time employee regularly scheduled to work at least 30 hours per week. First Data has no pre-existing condition exclusions for medical coverage that would prevent your eligibility during your initial enrollment. First Data is the sponsor of the Health and Welfare Benefit Plans. Certain subsidiaries and affiliates of First Data are also employers participating in the plans. Note: These are exceptions to the eligibility for coverage listed above. The Business Travel Accident Insurance Program includes all global employees (full- time and part-time), eligible guests and eligible interns on authorized First Data business travel. The Employee Assistance Program includes all U.S. based employees (full-time and part-time), their covered dependents, and their household members. Who Is Not Eligible If you are in one of these groups, you are not eligible for coverage under the plan: Employees scheduled to work less than 30 hours per week Employees not on the U.S. dollar payroll Temporary and/or seasonal employees including interns whether paid or unpaid Independent contractors (even if such person is later reclassified as an employee by any court or governmental agency for any reason). Persons rendering services pursuant to agreements describing them as independent contractors or employees of a leasing organization or working on assignment through any other outsource arrangements, or persons who have waived eligibility, are also not eligible to participate in these plans. Leased employees Employees subject to a collective bargaining agreement that does not provide for your participation Any other third-party personnel who perform services for the company Any others not listed here who do not meet the eligibility requirements Exceptions to Eligibility Rules Eligibility for the Severance Policy, Adoption Assistance Program, Business Travel and Accident Insurance Program, Employee Assistance Program (EAP) and Tuition Reimbursement Program is different, and explained in the applicable sections describing these programs. Automatic versus Elected Coverage If you meet the eligibility requirements: You receive some coverage automatically You can elect to participate in optional coverage 10
You choose the coverage you want and the dependents you want to cover You pay part or all of the cost of this coverage Coverage You Receive Automatically Once you satisfy the applicable waiting period and complete the applicable eligibility requirements, you receive coverage in these plans automatically: Basic Life Insurance (one times your annual benefits salary up to a maximum of $1,000,000 in coverage) Basic Accidental Death and Dismemberment Insurance (one times your annual benefits salary up to a maximum of $1,000,000 in coverage) Business Travel Accident Insurance (4 times your annual benefits salary to a maximum of $1,000,000 in coverage; certain plan limits apply) Short-Term Disability coverage Voluntary Long-Term Disability Insurance (60% of your annual monthly benefits salary and requires a payroll contribution made by you, the employee) Employee Assistance Program Severance Policy Coverage You Need to Elect Optional Coverage After meeting the eligibility requirements, you can enroll in these plans: Medical (if you are covering a spouse/domestic partner the dual coverage exclusion applies see Spouse/Partner Dual Coverage Exclusion section below) Tobacco-Free Incentive (elect to review the $350 Tobacco-Free Incentive if you or your enrolled spouse/domestic partner can both certify as nontobacco user; if you or your enrolled spouse/domestic partner does not certify as a non-tobacco user, you will pay an annual $250 Tobacco Surcharge and not receive the $350 Tobacco-Free Incentive; each are prorated across paychecks) Dental Vision Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Voluntary Accidental Death and Dismemberment Insurance Basic Long Term Disability Voluntary Long Term Disability Legal Assistance Plan Health Savings Account Health Care Flexible Spending Account Day Care Flexible Spending Account Care$ Benefit (available to employees who meet Day Care Flexible Spending Account and salary eligibility requirements) 11
If you do not enroll during the initial or annual enrollment period, you will be enrolled in only the coverage that is provided automatically and you will not be enrolled in any of the optional coverages. During the year, you can only change your coverage if you have a qualified change in status. When Coverage Begins For Newly Eligible Employees As an eligible full-time employee, your coverage in the following plans becomes effective on the first of the month following or coincident with your date of hire. Medical Tobacco-Free Incentive Dental Vision Basic Life Insurance Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Basic Accidental Death and Dismemberment Insurance Voluntary Accidental Death and Dismemberment Insurance Basic Long-Term Disability Voluntary Long-Term Disability Legal Assistance Plan Health Care Flexible Spending Accounts Health Savings Account Day Care Flexible Spending Account Care$ Benefit (if applicable based on eligibility) Health Screening Incentive automatically applied for new hires in 2016 (biometric health screening requirements must be met to earn future incentives) Your coverage in Business Travel Accident Insurance and the Employee Assistance Program begins your first day at work. Your coverage in the Short-Term Disability Plan begins on your 91st day at work. Eligibility Rules for Rehired Employees When you return to employment at the Company, the same eligibility rules that apply to new hires apply to you. If you have already met your waiting period, your eligibility will begin on your rehire date. Your coverage options depend on when you return to work. 12
Within 31 days - If you return in the same plan year (January 1 to December 31) in which you terminated, you receive the same coverage you had when your employment ended. If you return in a different plan year, you have an opportunity to enroll for new coverage. After 31 days - If you return in the same plan year (January 1 to December 31) in which you terminated, you receive the same coverage you had when your employment ended. An exception is the Health Care and Day Care Flexible Spending Accounts, in which you will need to enroll if you want to participate in that plan year. After 5 years If you return five years or more after your prior period of First Data employment, you are treated as a new hire with regard to health and life benefit eligibility. At Annual Enrollment For current employees making new coverage choices during annual enrollment, your new coverage begins on the next January 1. For Mid-Year Coverage Changes If you change your coverage as a result of a qualified change in status within the time limits provided (90 days for birth or adoption, 31 days for all other changes in status), your new coverage begins on the date of your status change event - for example, on the date you get married. If you do not elect to participate within the applicable deadlines, you must wait until the next annual enrollment period to enroll or make changes to your coverage. Dependents You Can Cover As an eligible employee, you can enroll your eligible dependents for coverage in these plans: Medical (spouse/domestic partner; Dual Coverage Exclusion applies) Dental Vision Spouse Life Insurance Child Life Insurance Voluntary Accidental Death and Dismemberment Employee Assistance Program (enrollment by dependent name is not required) As an eligible employee, you can enroll your domestic partner and same sex spouse for coverage in these plans only: Medical (spouse/domestic partner; Dual Coverage Exclusion applies) Dental Vision Spouse Life Insurance 13
Your eligible dependents include: Your legal spouse Children that meet dependent eligibility rules (refer to page 16 for definition) Domestic Partner Same Sex Spouse under any marriage certificate, civil union, or any other similar arrangement recognized under the state law of the state in which you reside. Ineligible Dependents include: Parents of employees Siblings of employees, unless they meet the age and dependent requirements as described in Dependent Eligibility Rules section below. All other relationships not specifically listed as an eligible dependent. If one or more of your dependents are eligible First Data employees, special rules apply (see the Employees in the Same Family section below). Dependent Verification Requirements After you enroll any dependent in First Data medical, dental or vision coverage, you will receive information regarding dependent verification. You will be required to provide specific documentation validating that your dependents meet eligibility requirements. You will receive your dependent verification information via correspondence home mailed approximately 14 days after you enroll your dependents in coverage. You must follow the instructions regarding the dependent verification process. If you do not comply with the dependent verification requests timely and accurately, your dependents will become ineligible for coverage. Specifically, any benefit coverage elected for the dependent(s) will be terminated on the date the dependent verification period expires. The dependent(s) will not be eligible to participate in the plans until the next annual enrollment period for the upcoming plan year, provided dependent verification of eligibility is completed. First Data may also conduct periodic dependent eligibility audits to ensure all dependents meet the eligibility qualifications. Employees found to be covering ineligible dependents will be subject to disciplinary action up to and including termination and coverage will be dropped for those dependents. Please note, that Federal Medicare regulations require you to provide a Social Security Number for each of your enrolled dependents. Dependents over the age of 1 will not be enrolled in the medical plan unless a valid Social Security Number is provided to the dependent verification administrator. 14
Spouse/Domestic Partner Coverage (Dual Coverage Exclusion) If your spouse/domestic partner is eligible for medical coverage through their employer (regardless of whether he or she is enrolled in that coverage) your spouse/domestic partner is NOT eligible for First Data medical coverage. If no employer coverage is available for the spouse/partner, you will be required to certify their eligibility for First Data coverage before you can enroll them in the medical plan coverage. The Dual Coverage Exclusion does not apply when you and your spouse/domestic partner both work for First Data. Domestic Partner Eligibility Rules If you are benefit eligible, you can enroll your same sex or opposite sex domestic partner in coverage under the company's medical, dental, vision, and life insurance plans provided you and your partner meet certain requirements. If your domestic partner is eligible for medical coverage through his or her employer (regardless of whether he or she is enrolled in that coverage) your domestic partner is NOT eligible for First Data medical coverage. If no employer medical coverage is available to your spouse/partner, you will be required to certify their eligibility for First Data coverage before you can enroll him/her in medical coverage. To be eligible for coverage, you and your partner must: Have shared a continuous, committed relationship for no less than six months, intend to do so indefinitely, and have no such relationship with any other person; Are mutually responsible for each other's welfare and share financial obligations; e.g., joint home ownership, joint checking account, joint automobile ownership or life insurance policy designating the other as the primary beneficiary; Have shared a common household for at least six months and intend to do so indefinitely; are not related by blood to a degree of kinship that would prevent marriage; Are not in a federally or state recognized marriage either by law or common law, or legally separated; Are both over the age of 18, of legal age to contract; and If you reside in a state, such as California, which has a domestic partner registry, you have registered. When adding your domestic partner to coverage you will certify online that you and your domestic partner meet the above requirements. You will be subject to taxes on imputed income for the coverage you choose for your domestic partner. If you marry an opposite sex domestic partner, you will no longer be subject to any imputed income. If you marry your same sex domestic partner, you may not be subject to imputed income in certain states. In either event, you must inform the First Data Health and Life Help Desk within 31 days following the date of 15
your marriage so that we will be able to ensure that the proper tax treatment is being applied. Dependent Eligibility Rules Definition of Eligible Dependents Your eligible dependents include your children, even if he or she has coverage available through his or her own employer for medical, dental, vision, and life insurance programs. For child life, your eligible dependents include your dependent children who are not working full time that you claim as dependents for federal income tax purposes or the children of your eligible domestic partner. The definition of an eligible child includes: your biological children, stepchildren, legally adopted children, children placed for adoption, foster children, children for whom you are the legal guardian, children of your domestic partner, children who you claim as a tax exemption as a non-custodial parent, or children you must cover under a Qualified Medical Child Support Order (QMCSO). Age Requirements You can cover your dependent children under Medical, Dental and Vision until the end of the month in which they reach age 26. For the Child Life Insurance and the Voluntary AD&D Insurance plans, you can cover a child until the end of the month in which he or she reaches age 19, or if they are a full-time student, until the end of the month in which he or she reaches age 23. You can cover a disabled child beyond the limiting ages above for as long as he or she remains eligible for coverage as defined in the corresponding benefit summary sections below. Please note, that Federal Medicare regulations require you to provide a Social Security Number for each of your enrolled dependents. Dependents over the age of 1 will not be enrolled in the Medical Plan unless a valid Social Security Number is provided to the enrollment administrator. Rules for Full-Time Students (Applies to Child Life and Voluntary AD&D Coverage) If an eligible child is a full-time student (according to the school's definition of full time), you can continue his/her Child Life Insurance and Voluntary AD&D Insurance benefits coverage after age 19. There will be no certification process for this coverage, however at the time the claim is submitted, if the child doesn t meet the eligibility requirements, the benefit will be denied. 16
You can continue his or her coverage until the end of the month in which your child reaches age 23 as long as your eligible child continues to be a full-time student throughout the year. If your eligible full-time student graduates they are able to continue coverage through the end of the month in which they graduate unless they find full time employment Rules for Disabled Children A disabled child age 26 or older is eligible for medical, dental, and vision benefits if he or she meets all of these criteria: Became disabled before age 26 Was covered under a First Data coverage option on the day coverage would have otherwise ended or is the disabled child of a newly eligible employee who was covered under a prior medical plan, and the disability commenced before the limiting age 26 Is incapable of self-support because of a mental or physical disability And is financially supported by you A disabled child age 19 or older is eligible for child life and voluntary AD&D benefits if he or she meets all of these criteria: Became disabled before age 19 (or age 23 if a full-time student) Was covered under a First Data coverage option on the day coverage would have otherwise ended or is the disabled child of a newly eligible employee who was covered under a prior plan, and the disability commenced before the limiting age 19 (or 23 if a full-time student) Is incapable of self-support because of a mental or physical disability And is financially supported by you Contact the First Data Health and Life Help Desk to learn how to certify his or her disability status with the claims administrator or carrier. See the Administrative Information section for the telephone number. For your child's coverage to continue, you or your claims administrator must contact the First Data Health and Life Help Desk when the disability status has been certified. See the Administrative Information section for the contact information. Disabled child coverage will end for any of these reasons: o The child is no longer incapacitated o The child becomes self-supporting o Proof of continued capacity is not obtained o Coverage ends for reasons other than reaching the limiting age of the plan Qualified Medical Child Support Order Certain court orders could require First Data's health plans to cover your child. This is known as a Qualified Medical Child Support Order. 17
The Company determines whether the court order is a Qualified Medical Child Support Order (QMCSO). If it is, the child gains eligibility for coverage. The child can also gain eligibility for coverage if the Company receives a National Medical Support Notice and determines it to be a QMCSO. In these situations, the Company can take deductions from your paychecks for your and the child's coverage. The plans cover the child from the first day of the month following the date the order is approved until the date or age stated in the order, but not beyond the normal eligibility age. The child is added to the coverage you are enrolled in. If a QMCSO requires someone other than you - for example, your ex-spouse - to provide health coverage for your child, you can drop coverage for that child if he or she actually becomes covered under the other person's plans. Contact the First Data Health and Life Help Desk as soon as you are aware of any court proceedings that may affect your child's eligibility for coverage under the Company's plans. See the Administrative Information section for the telephone number. Employees in the Same Family You are not eligible to be an enrolled dependent in the plans if you are enrolled for coverage as an employee. If you and your spouse/dependent both work for First Data, neither the employee, spouse or dependent may enroll as both the employee and spouse/dependent for coverage. The coverage restriction is valid for Supplemental Life, Spouse Life, Child Life, Medical, Dental, Vision, and Voluntary AD&D plans. If you enroll an ineligible person for any coverage, you will not be reimbursed for the cost of that coverage, and benefits under that coverage will be denied. Medical, Dental and Vision Coverage If you and your spouse/domestic partner are both benefit eligible First Data employees, you have these medical, dental and vision coverage options: You both can enroll for Employee Only coverage. One of you can enroll for Employee + Spouse (Domestic Partner) coverage. One of you can enroll for Employee Only coverage and the other can cover your eligible children by enrolling for Employee + Child(ren) coverage. One of you can enroll for Employee + Family coverage. If you and your eligible child are First Data employees, you have these medical, dental, and vision coverage options: You both can enroll for Employee Only coverage You can enroll for Employee + Child(ren) or Employee + Family coverage, as long as your dependent child meets the eligibility requirements. Employees of First Data can't be covered both as an employee and a dependent. Life and AD&D Insurance Coverage These rules apply to coverage under the life and accidental death and 18
dismemberment (AD&D) insurance plans when both you and your spouse are eligible employees: Both of you can enroll in supplemental employee life insurance (if you are not also covering each other under spouse life insurance). Either you or your spouse, but not both, can purchase child life insurance and/or voluntary AD&D insurance for your eligible children. Health Savings & Flexible Spending Account Coverage These rules apply to coverage under the flexible spending accounts when both you and your spouse are eligible employees: Both of you can enroll in the Health Care Flexible Spending Account, and each can contribute the maximum annual amount allowed to individuals. Both of you can enroll in the Day Care Flexible Spending Account, but your combined contributions can't exceed the maximum annual amount allowed by the IRS. Both of you can enroll in the Health Savings Account, and each can contribute the maximum annual amount allowed to individuals. 19
Enrollment Initial Enrollment You have 31 days from the date on your personalized enrollment worksheet to enroll for coverage. There are several resources available to provide you information about your health and life benefits and to help you complete your enrollment. Access the Your Benefits Resources website 24 hours a day, 7 days a week by connecting directly to http://resources.hewitt.com/firstdata, or through the benefits website at www.firstdatabenefits.us. Call Health Advocate at 1-866-799-2728, our patient advocate and assistance provider, to answer questions related to general benefits education, how the medical and dental plans work, finding providers and Employee Assistance Program services. Call the Health and Life Help Desk at 1-800-965-2238 and follow the prompts to answer questions related to vision, legal, disability, life, AD&D, business travel accident, flexible spending accounts, eligibility, enrollment, and adoption assistance. When you enroll, you need to provide personal information including the Social Security Number for each dependent you want to cover. Based on the dependents you enroll in coverage you will be assigned a coverage category. If you do not enroll within the 31 day deadline date, you are assigned basic coverage automatically however you will not be enrolled in any optional benefit coverage. Coverage will stay in effect until the next plan year (January 1 through December 31), unless you have a qualified change in status that allows you to change your coverage mid-year. Annual Enrollment Each fall, you ll be notified when it is time to enroll for the upcoming plan year. You must enroll during the annual enrollment period if: You want to cover a spouse/domestic partner in medical coverage you will need to verify their eligibility for medical coverage per the terms of the spouse/domestic partner Dual Coverage Exclusion requirement. You want to change any of your dependents, or your dependent's current coverage. You want to enroll a new dependent (previously eligible but not covered). You want to contribute pre-tax payroll contributions to the Health Savings Account You want to contribute pre-tax payroll contributions to the Health Care Flexible Spending Account or Day Care Flexible Spending Account for the upcoming year, and you are not a severed employee. 20
You want to receive the Care$ benefit for the upcoming year and you are not electing in the Day Care Flexible Spending Account (for all eligible employees meeting certain requirements; if eligible for Care$ Benefit and you elect the Day Care FSA, you are automatically enrolled in the Care$ Benefit). You want to receive the annual Tobacco-Free Incentive ($250 annual tobacco surcharge applied when you or enrolled spouse/domestic partner does not certify as non-tobacco user). You are enrolled in a plan option that will no longer be offered and do not want to be automatically assigned coverage. The company offers a new benefit plan in which you want to enroll. If you do not enroll, your current options, if available, are carried over to the next plan year with some exceptions: Your flexible spending account contributions (including Care$ Benefit) are discontinued at the end of the current plan year. Some life insurance plans restrict the amount by which you can increase your coverage in a single year. You will be subject to evidence of insurability (EOI) if you increase your coverage or start coverage after previously declining. This will be completed online on the enrollment website. Your spouse/domestic partner will be dropped from medical coverage if not re-certified as eligible for the new medical plan year (see Spouse/Domestic Partner Dual Coverage Exclusion in the Benefit Overview section). Other Enrollment Opportunities There are other times when you can enroll yourself or your eligible dependents for coverage. For example, if you or a dependent has a qualified change in status, you can change your coverage mid-year. Coverage Categories When you enroll for medical, dental or vision coverage, you enter information about the dependents you want to cover. They can include your spouse or domestic partner and/or any eligible children. After selecting which dependents to cover under the medical plans, you will then be assigned one of the following coverage categories for each plan: Individual Only (covering self-only) Family (covering self and one or more family members) After selecting which dependents to cover under the dental and vision plans, you will then be assigned one of the following coverage categories for each plan: Employee Only Employee + Spouse (or domestic partner) Employee + Child(ren) Employee + Family 21
You can have different coverage categories under the Medical, Dental, or Vision plans. All eligible dependents are covered automatically when you enroll in any of these plans: Spouse Life Insurance Legal Assistance Plan Voluntary Accidental Death and Dismemberment Insurance (if you elect family coverage) Employee Assistance Program (enrollment not required) You will select which dependents to cover under Child Life Insurance. If one or more family members are also eligible First Data employees, special rules apply (see Employees in the Same Family section in the Benefits Overview). At Other Enrollment Opportunities If you experience a qualified change in status, you may be eligible to change your coverage. If you don't submit new choices by the enrollment deadline (90 days for birth or adoption, 60 days for Special Children s Health Insurance Program, 31 days for all other events), no changes to your current elections will be made. If you move and your current medical and/or dental option is not available in your new area, no coverage will be assigned under the Medical or Dental Plan. If you change from part time to full time and gain eligibility for a plan, and you do not enroll, you are assigned no coverage. If you return from a leave that crossed plan years, you are assigned: Your current coverage under Long-Term Disability Your current coverage under Supplemental Employee Life Insurance provided that level of coverage is still available. If you become eligible to make new enrollment choices during the year, access the Your Benefits Resources website 24 hours a day, 7 days a week. Please refer to the When you Have Questions section on ways to access the Your Benefits Resources website. Changing Your Coverage Rules for Changing Employee Coverage Federal laws set specific rules about the types of coverage changes employees can make during the year. After you enroll in (or decline) coverage, your choices generally stay in effect for the rest of the plan year (January 1 through December 31). In special circumstances, however, you can enroll in coverage or change your choices during the plan year, except for the Long-Term Disability, Legal Assistance plan, Wellness Incentives. 22
During the plan year, you can start, increase, decrease or stop your Health Savings Account contributions at any time. Qualified Changes in Status During the plan year, you or your dependents can change your benefit coverage if a qualified change in status affects your or your dependents' eligibility under the First Data plans or another employer's plans. If you are eligible to make coverage changes, your changes must be consistent with the change in status. If you make a timely enrollment, (90 days for birth or adoption, 60 days for Special Children s Health Insurance Program, 31 days for other events) your new coverage begins on the date of your status change event- for example, on the date you get married. These situations qualify as a change in status: Your legal marital status or domestic partnership changes o You get married or enter into a domestic partnership. o You get divorced, legally separated, or have your marriage annulled. o Your domestic partnership ends. o Your spouse or domestic partner dies. The number of your eligible children changes o You have or adopt a child. o Your child gains or loses eligibility for coverage under the Health and Life Benefits. o Your child dies You move to a new address Your benefits eligibility changes because: o You take or return from a leave of absence. o You gain or lose eligibility as a result of a change in work schedule or status Your family member's benefits eligibility changes because of a change in his or her o Eligibility or coverage under another employer's plans: o He or she gains or loses eligibility as a result of a change in work schedule or status. o He or she gains a benefit option or loses coverage. o He or she makes new coverage choices during his or her employer's annual enrollment. You or your family member becomes entitled to or loses Medicare or Medicaid. You or your family member loses coverage under a government's or educational institution's plan. You gain or lose eligibility for another employer's group health plan. 23
Please Note: Your newborn child is covered under the Medical Plan, if temporary eligibility is established upon request of a claim, for the first 31 days from the date of birth. The newborn child is dropped from the Medical Plan coverage on the 32nd day if you have not enrolled the child into the Medical Plan due to a qualified change in status (birth of a child). You have 90 days from the date of birth to enroll the child. When you enroll between the 32nd and the 90th day, Medical Plan coverage for the child will be retroactive to the date of birth. You can enroll a newly eligible dependent on the enrollment site by selecting the Life Event link. Call the First Data Health and Life Help Desk for assistance. The Social Security Number for the newborn child must be provided by the child s first birthday to continue coverage. Please Note: In addition to any qualified change in status, if your day care provider (other than a relative) significantly changes its periodic charge during the year, or if you switch providers to one whose charges are significantly different, you will be permitted to elect a corresponding change in your contributions to your Day Care Flexible Spending Account. If you experience a qualified change in status, or are able to change your coverage for any of the reasons described above, you can make a midyear coverage change. To do so, go to the Life Events page on the enrollment site and choose the reason for your change, or contact the First Data Health and Life Help Desk for assistance. If You Get Married or Enter into a Domestic Partnership Allowable Changes: Medical, Dental and Vision Coverage: Enroll yourself if you are not already covered Add coverage for your spouse or domestic partner (dual coverage exclusion applies) Add coverage for any eligible children Drop coverage for yourself if you become covered under your spouse's or domestic partner's plan Drop coverage for any eligible children if they become covered under your spouse's or domestic partner's plan Select a different option Life and AD&D Insurance Coverage (you can enroll into, increase, decrease or drop coverage): Supplemental Employee Life Insurance Voluntary Accidental Death and Dismemberment Insurance Spouse Life Insurance Child Life Insurance 24
Long Term Disability Coverage Increase or decrease Flexible Spending Accounts (start, increase, decrease, or stop your contributions): Health Care Flexible Spending Account Day Care Flexible Spending Account, including Care$ Benefit (if eligible) Legal Assistance Coverage You can enroll into but you cannot drop coverage mid-year If You Get Divorced Allowable Changes: Medical, Dental and Vision Coverage Enroll yourself, if you are not already covered. Drop coverage for your ex-spouse. If your children are no longer covered under your ex-spouse's plan, you may enroll them. If your children are no longer considered eligible dependents, you must drop their coverage. If your children become newly eligible under your ex-spouse's plan, you may drop their coverage under your plan. Select a different option Life and AD&D Insurance Coverage (you can enroll into, decrease or drop coverage) Supplemental Employee Life Insurance Voluntary Accidental Death and Dismemberment Insurance Spouse Life Insurance (drop coverage only) Child Life Insurance Long Term Disability Coverage Increase or decrease coverage Flexible Spending Accounts (start, increase, decrease or stop contributions) Health Care Flexible Spending Account, Day Care Flexible Spending Account, including Care$ Benefit (if eligible) Legal Assistance Coverage You can enroll into but cannot drop coverage mid-year If You Have or Adopt a Child Allowable Changes: 25
Medical, Dental and Vision Coverage Enroll yourself if you are not already covered Add coverage for your spouse or domestic partner (dual coverage exclusion applies) Add coverage for any eligible children Drop coverage for yourself if you become covered under your spouse's or domestic partner's plan Drop coverage for any eligible children if they become covered under your spouse's or domestic partner's plan Select a different option Life and AD&D Insurance Coverage (enroll into, increase, decrease, or drop coverage) Supplemental Employee Life Insurance Voluntary Accidental Death and Dismemberment Insurance Spouse Life Insurance Child Life Insurance Long Term Disability Coverage Increase or decrease coverage Health Savings & Flexible Spending Accounts (start, increase, decrease or stop contributions) Health Savings Account Health Care Flexible Spending Account Day Care Flexible Spending Account, including Care$ Benefit (if eligible) Legal Assistance Coverage You can enroll into but cannot drop coverage mid-year If Your Child Gains Eligibility under the Health and Life Benefits Allowable Changes Medical, Dental and Vision Coverage Enroll yourself if you are not already covered Add coverage for your spouse or domestic partner (dual coverage exclusion applies) Add coverage for any eligible children You cannot change your coverage option if you are already enrolled. If the Child Will Be Covered Under Medical, Dental, and/or Vision Due to a QMCSO You Must: Enroll yourself if you are not already covered Add coverage for the affected child 26